Healthcare Provider Details

I. General information

NPI: 1134256092
Provider Name (Legal Business Name): MR. DAVID PICKUP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 BASE LINE RD BOX 400
LA VERNE CA
91750-2353
US

IV. Provider business mailing address

14815 BURBANK BLVD APT 8
VAN NUYS CA
91411-3340
US

V. Phone/Fax

Practice location:
  • Phone: 909-593-2581
  • Fax: 909-596-3567
Mailing address:
  • Phone: 818-481-2745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number51548
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: